Coding Rules
ACCD Classification Information Portal
Ref No: Q2644 | Published On: 15-Jun-2013 | Status: Current
Anaemia secondary to angiodysplasia of the colon
Q:
What codes should be used if a patient is admitted for anaemia secondary to angiodysplasia of the colon?
A:
Clinical advice confirms that the diagnostic statement 'anaemia secondary to angiodysplasia of the colon' indicates a
causal link, that is, there is bleeding from the site of the angiodysplasia resulting in the anaemia. Codes should be
assigned as follows:
Anaemia - D50.0 Iron deficiency anaemia secondary to blood loss (chronic) or D62 Posthaemorrhagic anaemia as
appropriate, following an index pathway such as:
Anaemia/due to/haemorrhage (chronic)
Anaemia/secondary to/blood loss (chronic)
Haemorrhage, haemorrhagic/anaemia (chronic)
Angiodysplasia - K55.22 Angiodysplasia of colon with haemorrhage following the index pathway:
Angiodysplasia/with haemorrhage.
Q:
Can angiodysplasia of the colon without haemorrhage still result in anaemia?
A:
Angiodysplasia will only cause anaemia when it bleeds.
Q:
Does the haemorrhage from the angiodysplasia have to be an overt haemorrhage, or can it be very slow and slight as
might be expected from a vascular lesion?
A:
The blood loss may be of varying degrees, from a low grade, chronic bleed, which may be indicated by a positive faecal
occult test or melaena, through to an acute, profound bleed which is life threatening.
Q:
Does the haemorrhage have to be present in the episode in order to code the angiodysplasia as 'with haemorrhage'?
A:
Bleeding from angiodysplasia is usually intermittent and therefore may not be apparent in the admission, however
where indicated by the clinical documentation, eg. 'angiodyplasia of colon with haemorrhage' or 'anaemia secondary to
angiodysplasia of the colon', the condition should be considered as being 'due to'/'with' haemorrhage .
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2680 | Published On: 15-Jun-2013 | Status: Current
Sedation and ventilation
Q:
Should a sedation code be assigned when sedation is administered for initiation of ventilation?
A:
Sedation that is administered to achieve anaesthesia for initiation of intubation/ventilation should be coded as per ACS
0031 Anaesthesia/2. Sedation.
Q:
Should a sedation code be assigned when ongoing sedation is administered with ventilation?
A:
Ongoing sedation is administered with many procedures for patient͛s comfort, control of anxiety and pain relief and
should not be coded.
Bibliography:
Hogarth, DK and Hall, J (2004), Management of sedation in mechanically ventilated patients, accessed: 23/4/2013, available: http://www.consensusconference.org/data/upload/consensus/1/pdf/737.pdf.
Brush, DR and Kress, JP (2009), Sedation and analgesia for the mechanically ventilated patient, Clinics in Chest Medicine, Vol. 30, No. 1, pp. ϭϯϭʹϭϰϭ͘
(Coding Q&A, June 2013)
Ref No: Q2730 | Published On: 15-Jun-2013 | Status: Current
Fluid overload, ESKD (end-stage kidney disease) and
pulmonary oedema
Q:
What should be assigned as the principal diagnosis for fluid overload with end-stage kidney disease (ESKD) with/without
pulmonary oedema?
A:
Fluid overload results from diseases where there is compromised regulation of sodium and water such as renal failure,
congestive heart failure (CHF) and liver failure. Fluid overload in a patient with ESKD may cause cardiopulmonary
complications such as pulmonary oedema (PO) and CHF. Patients may present with a combination of multiple cardiac
and/or liver diseases and/or non- compliance with treatment which may contribute to fluid overload.
The selection of principal diagnosis (PDx) for a patient admitted with fluid overload depends on what other conditions
are documented and the circumstances of the admission. Coders should be guided by ACS 0001 Principal
diagnosis/Problems and underlying conditions and ACS 0002 Additional diagnoses/Problems and underlying conditions.
Each case should be reviewed based on documentation and coders should seek clarification from the clinician where
there is uncertainty regarding the principal diagnosis.
References:
Galanes, S and Gulanick, M (2012), Fluid Volume Excess - Hypervolemia; Fluid Overload, Elsevier, accessed: 20 March 2013, available:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick22.html.
Ronco, C, Rossa Costanzo, M, Bellomo, R and Maisel, AS (2010), Fluid Overload: Diagnosis and Management, S.Karger AG, Basel (Switzerland).
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2719 | Published On: 15-Jun-2013 | Status: Current
Management of tracheostomy
Q:
Could the NCCC clarify in what circumstances it is appropriate to assign the following ACHI code:
90179-06 [568] Management of tracheostomy?
A:
Tracheostomy management includes care such as suctioning and cleaning. Assign 90179-06 [568] Management of
tracheostomy where management of the tracheostomy alone is provided during an episode of care.
Do not assign this code:





where the tracheostomy is initiated during the episode of care (see block [536] Tracheostomy)
where associated ventilatory support is being provided (see block [569] Ventilatory support)
for replacement or removal of tracheostomy tubes (see block [568] Airway management)
for revision of tracheostomy (41881-02 [541] Revision of tracheostomy)
for closure of tracheostomy (41879-02 [539] Closure of external fistula of trachea).
Q:
Could the NCCC clarify in what circumstances it is appropriate to assign the following ICD-10-AM code:
Z43.0 Attention to tracheostomy?
A:
Where a patient is admitted with an in situ tracheostomy which receives attention or management during the episode;
such as revision, closure, tube replacement, or cleaning, also assign Z43.0 Attention to tracheostomy. This code is not
assigned where there is a malfunction or complication of the tracheostomy, as in the excludes note at Z43.0.
Q:
Could the NCCC clarify in what circumstances it is appropriate to assign the following ICD-10-AM code:
Z93.0 Tracheostomy status?
A:
Assign Z93.0 Tracheostomy status where a patient is admitted with an in situ tracheostomy and it is determined that
the presence of the tracheostomy meets the criteria in ACS 0002 Additional diagnoses; however it does not fall within
the bounds of the scenarios cited above.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2723 | Published On: 15-Jun-2013 | Status: Current
Spontaneous premature rupture of membranes
Q:
Could the NCCC please clarify the coding of 'premature rupture of membranes', including whether there is a
requirement for the word 'spontaneous' to be specified?
A:
Premature rupture of membranes (PROM), also known as pre-labour rupture of membranes, is 'the spontaneous
rupture of the amniotic sac before the onset of labour' (Mosby, 2009). PROM can occur at term, that is, at or beyond
37 completed weeks of gestation, or preterm (PPROM), before 37 completed weeks of gestation, which can pose a
significant risk for morbidity and mortality in both the mother and the fetus, and is a major cause of preterm delivery
(Jazayeri, 2011).
The appropriate code for both term and preterm PROM is assigned following the index pathway:
Rupture, ruptured
- membranes (spontaneous)
- - premature
As 'spontaneous' is not an essential modifier it does not need to be specified in order to assign a code for premature
rupture of membranes, however it is implicit in the condition.
A code from O42 Premature rupture of membranes should not be assigned where membranes are ruptured artificially.
NCCC notes that a public submission has been submitted requesting index entries for 'pre-labour rupture of
membranes'. This will be considered along with other index entries for PROM and PPROM for a future edition of ICD-10
-AM.
References:
Jazayeri, A (2011), Premature rupture of membranes, Medscape reference, accessed: 11 February 2013, available: http://emedicine.medscape.com/article/261137-overview.
Mosby (2009), Mosby͛s Medical Dictionary, 8th edn, accessed: 11 February 2013, available: http://medical-dictionary.thefreedictionary.com/premature+rupture+of
+membranes.
(Coding Q&A, June 2013)
Ref No: Q2669 | Published On: 15-Jun-2013 | Status: Current
Principal diagnosis assignment for syndromes
Q:
Where a patient is admitted for treatment of a particular component of a syndrome, should a code for the syndrome
or the particular component, be assigned as the principal diagnosis?
A:
Where a patient presents for management of a component of a previously diagnosed syndrome, a code for the
component should be assigned as the principal diagnosis. Where ICD-10-AM:
 provides a specific code for the underlying syndrome, assign this code as an additional diagnosis (refer ACS 0001
Principal diagnosis/Problems and underlying conditions).
 does not provide a specific code for the underlying syndrome, refer to ACS 0005 Syndromes for instruction
regarding assignment of additional diagnosis codes.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2724 | Published On: 15-Jun-2013 | Status: Current
Transvenous abdominis plane (TAP) blocks
Q:
What is the correct code assignment for TAP blocks?
A:
A transversus abdominis plane (TAP) block is a regional block of the abdominal wall which is primarily used in
surgeries involving the lower abdominal wall, such as bowel surgery, appendicectomy, hernia repair and
gynaecological surgery. TAP blocks are also used for postprocedural pain and, less commonly, other pain
management.
TAP blocks can be administered via an injection or as a continuous or intermittent infusion, using either surface anatomy
landmarks or ultrasound guided technique to deposit local anaesthetic into the tissue plane between the internal
oblique and the transversus abdominis.
Assign codes for TAP blocks as follows:



for operative anaesthesia -- 92510-XX [1909] Regional block, nerve of trunk using index pathways:
Administration/nerve/for/operative anaesthesia/trunk Anaesthesia/conduction/regional block/nerve of/trunk
Block/nerve/for/operative anaesthesia/trunk Injection/nerve/for/operative anaesthesia/trunk
for postprocedural analgesia following initiation in theatre or recovery -- 92517-01 [1912] Management of regional
block, nerve of trunk using index pathways: Analgesia/postprocedural/management of/regional block/nerve of/trunk
Management/block/postprocedural/regional/trunk
for pain management anaesthesia -- 90022-00 [63] Administration of anaesthetic agent around other
peripheral nerve using the index pathway: Administration/nerve/peripheral
The addition of index entries for transversus abdominis plane (TAP) blocks will be considered for a future edition of ACHI.
Bibliography:
Webster, K (2008), The Transversus Abdominis Plane (TAP) block: abdominal plane regional anaesthesia,Update in Anaesthesia, Vol. 214, pp. 24-29.
(Coding Q&A, June 2013)
Ref No: Q2771 | Published On: 15-Jun-2013 | Status: Current
Obstetric principal diagnosis and delivery outcome
codes
Q:
What is the appropriate principal diagnosis and outcome of delivery code to assign in the following scenario:
Mother admitted to hospital after delivering Twin 1 by breech extraction in the ambulance on the way to hospital, then
delivers
Twin 2 by emergency caesarean section?
A:
O84.82 Multiple delivery by combination of methods should be assigned as the principal diagnosis and assign Z37.2
Twins, both liveborn as the outcome of delivery code.
Z39.03 Postpartum care after unplanned, out of hospital delivery should also be assigned to indicate that Twin 1 was
delivered prior to admission. As this is an exception to the guidelines in ACS 1548 Postpartum condition or complication
for assigning a code from Z39.0- Postpartum care and examination immediately after delivery as an additional diagnosis,
the standard will be reviewed for inclusion of this scenario in a future edition.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2758 | Published On: 15-Jun-2013 | Status: Current
Rusch balloon catheter for cervical ectopic pregnancy
bleeding
Q:
What is the correct code to assign for management of bleeding from a cervical ectopic pregnancy using a Rusch balloon
catheter?
A:
Cervical ectopic pregnancy is the rarest type of ectopic pregnancy, occurring in approximately 1 in 9,000
pregnancies. Initial presentation is usually profuse, painless vaginal bleeding. While it is potentially a life
threatening condition, it can be treated conservatively following an early diagnosis by ultrasound.
Cervical bleeding resulting from an ectopic pregnancy can be treated using a Rusch catheter. The catheter is placed
in the cervix and inflated with saline to create a balloon which places pressure on the blood vessels.
As ACHI does not contain a specific code for the insertion or replacement of Rusch catheters to control cervical
bleeding, the appropriate code to assign for both insertion and replacement is 35618-03 [1278] Other procedures on
cervix following the index pathway:
Procedure
- cervix NEC 35618-03 [1278]
The addition of index entries for Rusch balloon catheter for control of cervical bleeding will be considered for a future
edition of ACHI.
Bibliography:
Kirk, E and Bourne, T (2009), Diagnosis of ectopic pregnancy with ultrasound, Best Practice and Research Clinical Obstetrics and Gynaecology, Vol. 23, No. 4, pp. 501508. Heer, J, Chao, D and McPheeters, R (2012), Cervical ectopic pregnancy, West Journal of Emergency Medicine, Vol. 13, No. 1, pp. 125-126.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2788 | Published On: 15-Jun-2013 | Status: Current
Removal of urethral sling following male stress
incontinence procedure
Q:
What is the correct code to use for removal of urethral sling following male stress incontinence procedure?
A:
There is no specific procedure code for removal of urethral sling following previous stress incontinence procedure for
male patients. ACHI does not distinguish between removal and revision procedures for male stress incontinence. The
appropriate code for removal of a urethral sling for a male stress incontinence procedure is 37044-03 [1109] Revision
of retropubic procedure for stress incontinence, male following index pathways:
Revision (partial) (total)
- sling procedure for stress incontinence
- - female 35599-01 [1110]
- - male 37044-03 [1109]
Or
Sling procedure
- for
- - stress incontinence
- - - male 37044-00 [1109]
- - - - revision 37044-03 [1109]
- - - revision
- - - - female 35599-01 [1110]
- - - - male 37044-03 [1109]
NCCC will consider improvements to ACHI for this procedure for a future edition.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2794 | Published On: 15-Jun-2013 | Status: Current
Pressure injury
Q:
What is the correct code to assign for a pressure injury, documented as 'suspected deep tissue injury: depth unknown' or
'unstageable pressure injury: depth unknown'?
A:
In 2009, new definitions and a six stage classification for pressure injury were developed by the American National
Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). Australia and other Asia
Pacific countries adopted this new classification of pressure injuries in the 'Pan Pacific Clinical Guideline for the
Prevention and Management of Pressure Injury (Abridged Version)' (AWMA 2012).
The new clinical guideline uses the term 'pressure injury' for the synonymous terms pressure ulcer, decubitus ulcer
and bedsore; and has added two new stages of pressure injury to the existing four stage classification for those
pressure injuries where it is not possible to specify the depth, namely:
 Suspected deep tissue injury: depth unknown
 Unstageable pressure injury: depth unknown.
'Unstageable pressure injury: depth unknown' is defined as:
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green
or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to
expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV
(NPUAP & EPUAP 2009; NPUAP 2013).
'Suspected deep tissue injury: depth unknown' is defined as:
Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue
from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler
as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones.
Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin
eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment (NPUAP & EPUAP
2009; NPUAP 2013).
Currently there is no specific code in ICD-10-AM to classify 'suspected deep tissue injury: depth unknown' and
'unstageable pressure injury: depth unknown', however a proposal to update ICD-10 in line with the new guidelines
has been submitted to the WHO ICD-10 Update and Revision Committee (WHO-URC).
In the interim, clinical advice confirms that L89.9 Decubitus ulcer and pressure area, unspecified should be assigned
when either of these two new stages of pressure injury are documented.
References:
National Pressure Ulcer Advisory Panel (NPUAP) (2013), NPUAP Pressure Ulcer Stages/Categories, accessed: 6 March 2013, available:
http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/. National Pressure Ulcer Advisory Panel (NPUAP) and
European Pressure Ulcer Advisory Panel (EPUAP) (2009), International Guideline: Pressure Ulcer Treatment Technical Report, accessed: 6 March 2013, available:
http://www.npuap.org/wp-content/uploads/2012/03/Final-2009-Treatment-Technical-Report1.pdf. Australian Wound Management Association (AWMA) (2012),
Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury (Abridged Version), accessed: 6 March 2013, available:
http://www.awma.com.au/publications/2012_AWMA_Pan_Pacific_Abridged_Guideline.pdf.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: Q2808 | Published On: 15-Jun-2013 | Status: Current
Insertion of fiducial markers into the lung
percutaneously
Q:
What is the best procedure code to assign for insertion of fiducial markers into the lung percutaneously?
A:
Fiducial markers are metal markers implanted into a lesion or soft tissue as a radiographic reference point for provision
of external beam radiotherapy or radiosurgery. When used to treat lung cancer, the markers are inserted into the
lesion and its adjacent sites through needles, using a percutaneous approach. This procedure technically resembles
that of CT guided biopsy of lung (Sotiropoulou et al., 2013).
Currently there is no specific code in ACHI to classify insertion of fiducial markers into lung. Given the procedure is
technically similar to a CT guided biopsy, NCCC considers the best fit code to be 38812-00 [550] Percutaneous needle
biopsy of lung. This code can be accessed via index pathway:
Puncture
- lung 38812-00 [550]
Please note that 38456-02 [558] Other procedures on lung or pleura, intrathoracic approach is not an appropriate
code for this procedure as this intervention code is for lung procedures performed via an open intrathoracic
approach.
The NCCC will consider improvements to the classification of fiducial markers implantation for a future edition of ACHI.
References:
Sotiropoulou, E, Georgiadi, V, Stathochristopoulou, I, Stathopoulos, K, Salvaras, N and Thanos, L (2013), International Hospital Equipment & Solutions: CT-guided
fiducial implantation in radiosurgery of extracranial parenchymal cancer, accessed: 12 February 2013, available: http://www.ihe-online.com/feature-articles/ctguided-fiducial-implantation-in-radiosurgery-of-extracranial-parenchymal-cancer/.
(Coding Q&A, June 2013)
Ref No: TN474 | Published On: 15-Jun-2013 | Status: Current | Supersedes: TN207
Cystic fibrosis (3 of 3)
Q:
Does there have to be documentation in the clinical record linking the manifestation to the CF? Sometimes the clinical
record does not document the link although medical literature refers to linkage between CF and its manifestations. Can
the link be assumed in order to assign E84.-?
A:
There must be documentation in the clinical record that states a problem is a manifestation of CF in order for it to be
coded as one. If there is uncertainty as to whether a condition is a manifestation of CF, then the relationship between
the condition and CF should be verified with the clinician.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: TN474 | Published On: 15-Jun-2013 | Status: Current | Supersedes: TN207
Cystic fibrosis (2 of 3)
Q:
ACS 0402 Cystic Fibrosis states: "Cystic fibrosis should be coded with the appropriate code from E84.- Cystic fibrosis
followed by a code for any specified manifestation. Example 1: Patient admitted for reduction of fractured shaft of
tibia following fall from ladder. Patient also treated for bronchiectasis associated with cystic fibrosis. Codes: S82.28
Other fracture of shaft of tibia W11 Fall on and from ladder An appropriate place of occurrence code (Y92.-) and activity
code (U50-U73) E84.0 Cystic fibrosis with pulmonary manifestations J47 Bronchiectasis If the patient mentioned in
Example 1 above did not have treatment for their CF and/or the manifestation(s) then code(s) would not be assigned
for CF. Is this correct?
A:
If cystic fibrosis or its manifestations do not meet the criteria for code assignment as per the guidelines in ACS 0001
Principal diagnosis or ACS 0002 Additional diagnoses, there is no requirement to code these conditions. ACS 0402
provides guidance on how cystic fibrosis should be coded, rather than whether or not it should be coded in the first
instance.
(Coding Q&A, June 2013)
Ref No: TN474 | Published On: 15-Jun-2013 | Status: Current | Supersedes: TN207
Cystic fibrosis (1 of 3)
Q:
When a patient is admitted with cystic fibrosis (CF) and has manifestations, how should they be coded in the following
scenario?
Patient admitted for surgery for nasal polyps (where nasal polyps are documented as a manifestation of CF).The
patient also has bronchiectasis and pancreatic insufficiency due to CF. Do the manifestations of bronchiectasis and
pancreatic insufficiency have to meet ACS 0002 Additional diagnoses to be coded? Which E84.- code should be
assigned?
A:
When determining whether cystic fibrosis or its manifestations should be coded, refer to the guidelines in ACS 0001
and ACS 0002, as well as the guidelines specified in ACS 0402 Cystic fibrosis. In this scenario nasal polyps meet the
criteria for code assignment as per ACS 0001 Principal diagnosis, and then ACS 0402 specifically states: "Cystic fibrosis
should be coded with the appropriate code from E84.- Cystic fibrosis... followed by a code for any specified
manifestation.
More than one code from E84.- Cystic fibrosis should be used if the patient presents with multiple
manifestations of CF." Therefore, for the above scenario assign the following codes:
E84.8 Cystic fibrosis with other specified manifestations
J33.9 Nasal polyp, unspecified
E84.0 Cystic fibrosis with pulmonary manifestations
J47 Bronchiectasis
K86.8 Other specified diseases of pancreas.
When cystic fibrosis meets the criteria for code assignment as per ACS 0001 Principal diagnosis or ACS 0002 Additional
diagnoses, all manifestations should be coded regardless of whether they meet ACS 0002.
(Coding Q&A, June 2013)
Current as at 17-Jun-2014 05:24
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Coding Rules
ACCD Classification Information Portal
Ref No: TN393 | Published On: 15-Jun-2013 | Status: Current | Supersedes: TN207
Viral hepatitis
Viral hepatitis
Patients with chronic viral hepatitis are often asymptomatic or may have abnormal liver function tests (LFTs). An
indication of chronic viral hepatitis is a raised level of alanine transaminase (ALT) and/or aspartate aminotransferase
(AST), in the absence of other causes of liver inflammation such as alcohol, non-alcoholic fatty liver disease. Generally,
patients with chronic viral hepatitis are followed up 6-12 monthly with blood tests. Six monthly ultrasounds are
recommended for surveillance of hepatocellular carcinoma (primary liver cancer) in all patients with cirrhosis, and in
some patients with chronic HBV infection in the absence of cirrhosis.
Generally, after recovery from an infection with an organism, a person will develop antibodies to the pathogenic
organism. Antibodies to certain infectious diseases can also be produced by vaccination. In these vaccinated
people, future blood tests demonstrating the antibodies will indicate past infection or immunisation. Detection
of antibodies does not indicate active infection; this is confirmed by detecting the virus in the blood. A person
with detectable virus in their blood may or may not manifest symptoms but is potentially infectious and the virus
can be transmitted to others.
It is important to understand the distinction between a person who has an active infection (at risk of transmission of
infection to others and disease progression) and a person whose antibody results indicate past infection or
immunisation to an infectious disease (not an infection risk, and usually not at risk of disease progression). The role of
antibody tests in distinguishing between disease status and past infection varies depending on the infection. In some
situations, testing for viral nucleic acid (DNA or RNA) is required to determine if actual infection is present.
Hepatitis A
Transmission within families is common. In developing countries, the usual source of infection is faecal contamination
of drinking water. The hepatitis A virus (HAV) is detected by two antibody tests:
1. IgM antibody: positive result indicates recent infection. 2. IgG antibody (anti-HA): positive result indicates past
infection
(previous exposure to HAV) or immunity through vaccination.
Hepatitis B
Most people who are infected with HBV as adolescents or adults do not develop symptoms and clear infection
spontaneously - they make a full recovery and are left with immunity for life. However, following acute infection, a
small minority (approximately 5%) of patients will progress to a chronic infection.
In contrast, most of the global burden of chronic hepatitis B results from mother to infant transmissions or infection in
early childhood, in high prevalence countries. Newborn babies of mothers who have hepatitis B (HBsAg positive) are at
risk of infection and should receive HBV vaccination and immunoglobulin (within 12 hours of birth and complete a full
HBV vaccination schedule). People who are infected with HBV as infants or in early childhood are often asymptomatic,
but usually progress to chronic HBV infection.
There are two categories of tests used to diagnose and manage HBV infection:
1. serological assays: enzyme immunoassay (EIA) detects specific antibody(ies) to HBV and antigen(s) and includes
HBsAg, anti-HBs, HBeAg, anti-HBe, anti-HBcAg. 2. molecular assays: detect and/or quantify the amount of viral
nucleic acid (HBV DNA [deoxyribonucleic acid]). Tests are divided into two types:


qualitative assays: detects presence or absence of HBV DNA
quantitative assays: measures the amount of HBV DNA ('viral load') in serum (this is the preferred testing
method and includes polymerase chain reaction (PCR) and transcription-mediated amplification (TMA) assays).
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Antiviral therapy is used to treat patients with HBV infection, with the current aim of treatments to suppress virus
replication and prevent progression of liver disease (EASL 2012). Spontaneous clearance of HBV infection may occur
without treatment. This is common in adults following acute infection, but can also occur in people with chronic HBV
infection. Resolution of HBV infection is rare with current treatment. Resolved HBV infection is defined as 'previous
HBV infection without further virologic, biochemical or histological evidence of active virus or disease' (Lok &
McMahon 2009, p. 4).
Hepatitis C
The majority of patients (60-70%) with acute HCV infection will progress to a chronic infection. Spontaneous viral
clearance after acute HCV infection occurs without treatment in 30-40% of people, usually within the first 6 months
after infection. There are two categories of tests used to diagnose and manage HCV infection:
1. serological assays: enzyme immunoassay (EIA) detects specific antibody to HCV (anti-HCV) 2. molecular assays:
detect and/or quantify the amount of viral nucleic acid (HCV RNA [ribonucleic acid]). Tests are divided into three
types:
 qualitative assays: detects presence or absence of HCV RNA
 quantitative assays: measures the amount of HCV RNA ('viral load') in serum. This is usually by polymerase chain
reaction (PCR).
 genotype assay: there are 6 main genotypes of HCV. Choice and duration of antiviral treatment, as well as
likelihood of response is strongly related to the infecting genotype.
Antiviral therapy is used to treat patients with HCV infection, with the aim of virological cure. Therapy is for a defined
time period, usually 24 or 48 weeks. HCV infection is considered to be successfully treated when SVR (sustained
virological response) is attained. SVR is defined as the absence of HCV RNA in serum 24 weeks after discontinuing
therapy (Ghany et al. 2009, p. 1341).
Hepatitis D
Testing for HDV involves serology for hepatitis D antibodies (anti-HDV). However, this does not allow
determination of active infection or prior exposure. Hepatitis D virus RNA testing has only limited availability in
research settings.
Hepatitis E
It is endemic in South-East Asia, countries of the Soviet region, India, mid-east Africa and Central America. Large
outbreaks are usually spread by contaminated water. Direct person to person spread can occur but is less common.
The normal course of infection is an acute and a relatively benign illness. Whereas, HEV in pregnancy can cause
fulminant hepatic failure, particularly in the third trimester, with mortality rates of 15-25%.
It was previously thought that HEV is never a chronic infection. However, it has been recently recognised that hepatitis E
may result in chronic infection, particularly in immunosuppressed individuals such as organ transplant recipients (Kamar
et al. 2012, p. 6).
Ackowledgements:
The NCCC would like to thank Dr Mark Douglas, Associate Professor Simone Strasser and Associate Professor Stuart
Roberts for their invaluable contribution to updating viral hepatitis in the classification system.
References:
European Association for the Study of the Liver (EASL) 2012, 'EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection', Journal of Hepatology,
vol. 57, pp. 167-185.
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(Coding Q&A, June 2013)
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